Decision-makingthan a quarter of <strong>the</strong> <strong>to</strong>tal disease burden. In contrast, inLatin America <strong>and</strong> <strong>the</strong> Caribbean, <strong>the</strong>se diseases accountedfor 8% of disease burden. However, this region also had highlevels of diabetes <strong>and</strong> endocrine disorders compared witho<strong>the</strong>r regions. Violence was <strong>the</strong> third leading cause of burdenin Latin America <strong>and</strong> Caribbean countries, but did not <strong>reach</strong><strong>the</strong> <strong>to</strong>p 10 in any o<strong>the</strong>r region.HIV/AIDS was <strong>the</strong> leading cause of burden of disease insub-Saharan Africa, followed by malaria. Seven o<strong>the</strong>r GroupI causes also appear in <strong>the</strong> <strong>to</strong>p 10 causes for this region, withroad traffic accidents being <strong>the</strong> only non-Group I cause.Group I, II, <strong>and</strong> III causes all appear among <strong>the</strong> <strong>to</strong>p 10causes of <strong>the</strong> disease burden for <strong>the</strong> Middle East <strong>and</strong> NorthAfrica. Of particular note, road traffic accidents were <strong>the</strong> thirdleading cause <strong>and</strong> congenital anomalies were <strong>the</strong> seventhleading cause.Group I causes of disease burden remained dominant inSouth Asia, <strong>and</strong> this burden fell particularly on children, butnoncommunicable diseases such as IHD, stroke, <strong>and</strong> chronicobstructive pulmonary disease also featured in <strong>the</strong> list of <strong>to</strong>p10 causes.In East Asia <strong>and</strong> <strong>the</strong> Pacific, stroke was <strong>the</strong> leading causeof disease burden in 2001, with IHD in fourth place,although Group I causes such as conditions arising during<strong>the</strong> perinatal period, TB, lower respira<strong>to</strong>ry infections, <strong>and</strong>diarrhoeal diseases remained important.ConclusionsThe analysis presented has confirmed some of <strong>the</strong>conclusions of <strong>the</strong> original GBD study about <strong>the</strong> importanceof including nonfatal outcomes in a comprehensiveassessment of global population <strong>health</strong>, <strong>and</strong> has alsoconfirmed <strong>the</strong> growing importance of noncommunicablediseases in low- <strong>and</strong> middle-income countries. However, ithas also documented some dramatic changes in population<strong>health</strong> in some regions since 1990. The key findings include<strong>the</strong> following:✜ HIV/AIDS is now <strong>the</strong> fourth leading cause of <strong>the</strong> burdenof disease globally <strong>and</strong> <strong>the</strong> leading cause in sub-SaharanAfrica.✜ In low- <strong>and</strong> middle-income countries, <strong>the</strong>epidemiological transition has resulted in a 20%reduction in <strong>the</strong> per capita disease burden due <strong>to</strong> GroupI causes since 1990. Without <strong>the</strong> HIV/AIDS epidemic,this reduction would have been closer <strong>to</strong> 30%. Severalof <strong>the</strong> “traditional” infectious diseases, such as TB <strong>and</strong>malaria, have not declined, in part because of weakpublic <strong>health</strong> services <strong>and</strong> <strong>the</strong> increased numbers ofpeople with immune systems weakened by HIV/AIDS.✜ The per capita disease burden in Europe <strong>and</strong> CentralAsia increased by nearly 40% during 1990–2001,meaning that this region now has worse <strong>health</strong> than allo<strong>the</strong>r regions except South Asia <strong>and</strong> sub-Saharan Africa.The unexpected increase in <strong>the</strong> disease burden, <strong>and</strong> <strong>the</strong>concomitant reduction in life expectancy, in countries ofthis region appear <strong>to</strong> be related <strong>to</strong> such fac<strong>to</strong>rs asalcohol abuse, suicide, <strong>and</strong> violence, which seem <strong>to</strong> beassociated with societies facing <strong>social</strong> <strong>and</strong> economicdisintegration. The rapidity of <strong>the</strong>se declines hasdramatically changed our perceptions of <strong>the</strong> time frameswithin which substantial changes in <strong>the</strong> burden ofchronic disease can occur <strong>and</strong> of <strong>the</strong> potential for suchadverse <strong>health</strong> trends <strong>to</strong> occur elsewhere.✜ Adults under <strong>the</strong> age of 70 in low- <strong>and</strong> middle-incomecountries face a substantially greater risk of death fromnoncommunicable diseases than adults of <strong>the</strong> same agein high-income countries.✜ In Europe <strong>and</strong> Central Asia, Latin America <strong>and</strong> <strong>the</strong>Caribbean, <strong>and</strong> <strong>the</strong> Middle East <strong>and</strong> North Africa, morethan 30% of <strong>the</strong> entire disease burden among maleadults age 15 <strong>to</strong> 44 is attributable <strong>to</strong> injuries, includingroad traffic accidents, violence, <strong>and</strong> self-inflicted injuries.In addition, injury deaths are noticeably higher forwomen in some parts of Asia <strong>and</strong> <strong>the</strong> Middle East <strong>and</strong>North Africa than in o<strong>the</strong>r regions, partly because ofhigh levels of suicide <strong>and</strong> violence. Combined withhigher rates of infant <strong>and</strong> child mortality for girls, thisresults in a narrower differential between male <strong>and</strong>female <strong>health</strong>y life expectancy than in any o<strong>the</strong>r region. ❏Alan Lopez is Professor of Medical Statistics <strong>and</strong> PopulationHealth <strong>and</strong> Head of <strong>the</strong> School of Population Health at <strong>the</strong>University of Queensl<strong>and</strong>. Prior <strong>to</strong> joining <strong>the</strong> University in January2003, he worked at <strong>the</strong> World Health Organization (WHO) inGeneva, Switzerl<strong>and</strong>, for 22 years where he held a series oftechnical <strong>and</strong> senior managerial posts including ChiefEpidemiologist in WHO’s Tobacco Control Program (1992–95),Manager of WHO’s Program on Substance Abuse (1996–98),Direc<strong>to</strong>r of <strong>the</strong> Epidemiology <strong>and</strong> Burden of Disease Unit(1999–2001), <strong>and</strong> Senior Science Advisor <strong>to</strong> <strong>the</strong> Direc<strong>to</strong>r-General(2002).Colin Ma<strong>the</strong>rs is Coordina<strong>to</strong>r of <strong>the</strong> Country Health Informationteam in <strong>the</strong> Evidence <strong>and</strong> Information for Policy Cluster at <strong>the</strong>World Health Organization (WHO) in Geneva, Switzerl<strong>and</strong>. He isresponsible for WHO reassessments of <strong>the</strong> global burden ofdisease, <strong>and</strong> in <strong>the</strong> development of software <strong>to</strong>ols <strong>to</strong> supportburden of disease analysis at country level.174 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingReferences1.Bannister J <strong>and</strong> Hill K. Mortality in China, 1964–2000. PopulationStudies, 2004, 58 (1): 55–75.2.Lopez AD, Ahmad O, Guillot M et al. World Mortality in 2000: Life Tablesfor 191 Countries. Geneva: World Health Organization, 2002.3.Lopez, AD, Begg S <strong>and</strong> Bos E. Demographic <strong>and</strong> epidemiologicalcharacteristics of major regions, 1990–2001, pp. 17-44 in Lopez AD,Ma<strong>the</strong>rs CD, Ezzati M, Jamison DT, Murray CJL (eds.), Global Burden ofDisease <strong>and</strong> Risk Fac<strong>to</strong>rs. Disease Control Priorities Review, Volume 2,2006. New York: Oxford University Press <strong>and</strong> The World Bank (copublication).4.Lopez AD et al. (Eds). Global Burden of Disease <strong>and</strong> Risk Fac<strong>to</strong>rs.Disease Control Priorities Review, Volume 2, 2006. New York: OxfordUniversity Press <strong>and</strong> The World Bank (co-publication).5.Ma<strong>the</strong>rs CD, Lopez AD <strong>and</strong> Murray CJL. The Burden of Disease <strong>and</strong>Mortality by Condition: Data, Methods <strong>and</strong> Results for 2001, pp. 45-240in Lopez AD et al. (Eds.), Global Burden of Disease <strong>and</strong> Risk Fac<strong>to</strong>rs.Disease Control Priorities Review, 2006, Volume 2. New York: OxfordUniversity Press <strong>and</strong> The World Bank (co-publication).6.Murray CJL et al. Modified Logit Life Table System: Principles, EmpiricalValidation, <strong>and</strong> Application. Population Studies, 2003, 57 (2): 1–18.7.Murray CJL <strong>and</strong> Lopez AD. 1996a. Estimating Causes of Death: NewMethods <strong>and</strong> Global <strong>and</strong> Regional Applications for 1990. In The GlobalBurden of Disease (ed.) Murray CJL <strong>and</strong> Lopez AD, pp. 117-200. Vol. 1of Global Burden of Disease <strong>and</strong> Injury Series. Cambridge, MA: HarvardUniversity Press. Murray CJL <strong>and</strong> Lopez AD. 1996b. Evidence-BasedHealth Policy: Lessons from <strong>the</strong> Global Burden of Disease Study.Science, 274 (5288): 740–43. Murray CJL <strong>and</strong> Lopez AD (eds.). 1996c.The Global Burden of Disease: A Comprehensive Assessment of Mortality<strong>and</strong> Disability from Diseases, Injuries, <strong>and</strong> Risk Fac<strong>to</strong>rs in 1990 <strong>and</strong>Projected <strong>to</strong> 2020. Vol. 1 of Global Burden of Disease <strong>and</strong> Injury Series.Cambridge, MA: Harvard University Press. Murray CJL <strong>and</strong> Lopez AD.1997a. Global Mortality, Disability, <strong>and</strong> <strong>the</strong> Contribution of Risk Fac<strong>to</strong>rs:Global Burden of Disease Study. The Lancet, 349 (9063): 1436–42.Murray CJL <strong>and</strong> Lopez AD. 1997b. Mortality by Cause for Eight Regionsof <strong>the</strong> World: Global Burden of Disease Study. The Lancet, 349 (9061):1269–76.8.Mari Bhat PN. Completeness of India’s Sample Registration System: AnAssessment Using <strong>the</strong> General Growth Balance Method. PopulationStudies, 2002, 56 (2): 119–34.9.Roglic G et al. The Realistic Burden of Mortality Attributable <strong>to</strong> Diabetes:Estimates for <strong>the</strong> Year 2000. Diabetes Care, 2005, 28 (9): 2130-2135.Global Forum Update on Research for Health Volume 4 ✜ 175